Strategies to improve delivery of equitable and evidence-informed care for pregnant and birthing people with a substance use disorder in acute care settings: A scoping review protocol.

This protocol outlines a proposed scoping review to characterize evidence on implementation and quality improvement (QI) strategies that aim to improve equitable, evidence-informed care delivery for pregnant and birthing people with substance use disorder (SUD) in acute care. Untreated SUD during pregnancy is associated with an increased risk of overdose and severe maternal morbidity. Acute care settings are one important place to deliver equitable, evidence-informed clinical care. While clinical practice guidelines for substance use treatment and care of pregnant and birthing people with SUD exist, there are gaps in implementation. Our population of interest is pregnant and birthing people with SUD in an acute care setting. We will include US-based studies that describe or evaluate implementation or QI strategies, including experimental, observational, and descriptive studies published from 2016 to 2023. The proposed scoping review will be conducted in accordance with JBI methodology for scoping reviews and registered at OSF (registration number: BC4VZ). We will search MEDLINE (PubMed), CINAHL Complete (EBSCO), Scopus (Elsevier), and APA PsychInfo (Ovid) for published studies. Conference proceedings and Perinatal Quality Collaborative websites will be searched for grey literature. Two reviewers will independently screen then extract studies that meet inclusion criteria using a data extraction tool. The completion of this scoping review will help illuminate strengths and gaps in research and practice that aim to inform substance use treatment and care in acute care settings for pregnant and birthing people with SUD.

A Clinical Guide to Support the Implementation of Addiction Consult Services and the Value of Teaching and Technical Assistance.

ABSTRACT: People with substance use disorders (SUDs) are increasingly admitted to general hospitals; however, many hospital systems lack both formal structures and skilled staff to provide high-quality care for inpatients with SUDs. Inpatient addiction consult services (ACSs), which are increasingly being implemented around the country, are an evidence-based strategy to add focused care for people with SUDs into the general medical setting. In 2018, New York City Health + Hospitals (H + H) launched an ACS program called Consult for Addiction Care and Treatment in Hospitals in six hospitals, supported by a team of addiction consult experts to deliver teaching and technical assistance (TTA) for the Consult for Addiction Care and Treatment in Hospitals ACSs. This commentary describes the TTA, which included site visits, introductory educational lectures, case conferences, ad hoc support, implementation assistance, and the creation of an addiction care guide. Similar TTA services could be used in the future when hospitals or systems want to launch novel clinical programs.

Integrating substance use peer support and screening brief intervention and referral to treatment services in the emergency department: a descriptive study of the ED leads program.

BACKGROUND: The ED Leads program was introduced to 11 emergency departments (EDs) within New York City public hospitals from 2018 to 2019 to address a need for addiction support services in the ED. The purpose of this study is to (i) describe the ED Leads blended licensed-clinician and peer counselor team model in the ED at three hospitals, (ii) provide a descriptive analysis of patient engagement and referrals to substance use disorder (SUD) care post-intervention, and (iii) highlight potential barriers and facilitators to implementing the model. METHODS: The program intended to combine Screening Brief Intervention and Referral to Treatment and peer support services. The authors analyzed electronic medical records data for patients encountered by ED Leads in the first 120 days of program launch. Data included the outcome of an encounter when a patient was engaged with one or both staff types, and 7-day attendance at an SUD treatment appointment when a patient accepted a referral within the 11-hospital system. RESULTS: There were 1785 patients approached by ED Leads staff during the study period. Engagement differed by staff type and patient demographics, and encounter outcomes varied significantly by hospital. Eighty-four percent (N = 1503) of patients who were approached engaged with at least one staff type, and 6% (N = 86) engaged with both. Patients were predominantly male (N = 1438, 81%) with an average age of 45 (SD = 13), and enrolled in Medicaid (N = 1062, 59%). A majority (N = 801, 45%) had alcohol use disorder. Of the patients who accepted a referral within the system (N = 433), 63% received treatment services within 7 days of the ED Leads encounter, a majority at detoxification treatment (N = 252, 58%). CONCLUSIONS: This study describes the potential value and challenges of implementing a blended peer counselor and licensed clinician model in the ED to provide SUD services. While teams provided a high volume of referrals and the analysis of post-intervention treatment follow up is promising, the blended team model was not fully realized, making it difficult to assess the benefits of this combined service. Further research might examine patient outcomes among ED patients who are offered services by both a peer counselor and licensed clinician.

Pandemic telehealth flexibilities for buprenorphine treatment: a synthesis of evidence and policy implications for expanding opioid use disorder care in the United States.

Buprenorphine is a highly effective treatment for opioid use disorder (OUD) and a critical tool for addressing the worsening US overdose crisis. However, multiple barriers to treatment-including stringent federal regulations-have historically made this medication hard to reach for many who need it. In 2020, under the COVID-19 public health emergency, federal regulators substantially changed access to buprenorphine by allowing prescribers to initiate patients on buprenorphine via telehealth without first evaluating them in person. As the public health emergency has been set to expire in May of 2023, Congress and federal agencies can leverage extensive evidence from studies conducted during the wake of the pandemic to make evidence-based decisions on the regulation of buprenorphine going forward. To aid policy makers, this narrative review synthesizes and interprets peer-reviewed research on the effect of buprenorphine flexibilities on the uptake and implementation of telehealth, and its impact on OUD patient and prescriber experiences, access to treatment, and health outcomes. Overall, our review finds that many prescribers and patients took advantage of telehealth, including the audio-only option, with a wide range of benefits and few downsides. As a result, federal regulators-including agencies and Congress-should continue nonrestricted use of telehealth for buprenorphine initiation.

Pathways to racial disparities in the effects of Good Samaritan Laws: A mixed methods pilot study.

BACKGROUND: Drug overdose deaths continue to rise, and considerable racial inequities have emerged. Overdose Good Samaritan laws (GSLs) are intended to encourage overdose witnesses to seek emergency assistance. However, evidence of their effectiveness is mixed, and little is known regarding racial disparities in their implementation. This study examined GSL impact by assessing racial differences in awareness of and trust in New York state's GSL. METHODS: Using a sequential mixed methods design, Black and white participants were recruited from an existing longitudinal cohort study of people who use illicit opioids in New York City to participate in a quantitative survey and qualitative interviews. Racially stratified survey responses were analyzed using chi-squared tests, Fisher exact tests, or t-tests. Qualitative interviews were analyzed using a hybrid inductive-deductive approach. RESULTS: Participants (n=128) were 56% male and predominantly aged 50 years or older. Most met criteria for severe opioid use disorder (81%). Fifty-seven percent reported that the New York GSL makes them more likely to call 911 even though 42% reported not trusting law enforcement to abide by the GSL; neither differed by race. Black people were less likely to have heard of the GSL (36.1% vs 60%) and were less likely to have accurate information regarding its protections (40.4% vs 49.6%). CONCLUSIONS: Though GSLs may reduce negative impacts of the criminalization of people who use drugs, their implementation may exacerbate existing racial disparities. Resources should be directed towards harm reduction strategies that do not rely on trust in law enforcement.

Telephonic Outreach to Engage Patients with Substance Use Disorder Post-Hospitalization During the COVID-19 Pandemic.

During the initial COVID-19 surge, one public hospital in NYC updated their post-discharge outreach approach for patients with substance use disorder, as part of the CATCH (Consult for Addiction Treatment and Care in Hospitals) program. Beginning April 1, 2020, three peers and two addiction counselors attempted telephonic outreach to patients who received a CATCH consultation during hospitalization from program launch (October 7, 2019) through March 31, 2020 (n = 329). Outreach calls could include counseling, in-depth peer support, and referrals to substance use services (SUS)-a significant expansion of the services offered via outreach pre-pandemic. CATCH staff successfully reached 29.5% of patients and provided 77.6% of them with supportive counseling and referrals. Thirty percent of unsuccessful calls were due to inactive numbers, and only 8% of patients without housing were reached. Telephonic outreach established a low-barrier connection between patients and SUS that may be valuable during any period, including non-COVID times. Future interventions that address social determinants such as housing and cell phone access concomitantly with substance use should be considered by addiction consultation services to potentially reduce acute care utilization and improve health outcomes.

Pandemic telehealth flexibilities for buprenorphine treatment: A synthesis of evidence and policy implications for expanding opioid use disorder care in the U.S.

Buprenorphine is a highly effective treatment for opioid use disorder and a critical tool for addressing the worsening U.S. overdose crisis. However, multiple barriers to treatment - including stringent federal regulations - have historically made this medication hard to reach for many who need it. In 2020, under the COVID-19 Public Health Emergency, federal regulators substantially changed access to buprenorphine by allowing prescribers to initiate patients on buprenorphine via telehealth without first evaluating them in person. As the Public Health Emergency is set to expire in May of 2023, Congress and federal agencies can leverage extensive evidence from studies conducted during the wake of the pandemic to make evidence-based decisions on the regulation of buprenorphine going forward. To aid policy makers, this review synthesizes and interprets peer-reviewed research on the effect of buprenorphine flexibilities on uptake and implementation of telehealth, and its impact on OUD patient and prescriber experiences, access to treatment and health outcomes. Overall, our review finds that many prescribers and patients took advantage of telehealth, including the audio-only option, with a wide range of benefits and few downsides. As a result, federal regulators-including agencies and Congress-should continue non-restricted use of telehealth for buprenorphine initiation.

Persistent Criminalization and Structural Racism in US Drug Policy: The Case of Overdose Good Samaritan Laws.

The US overdose crisis continues to worsen and is disproportionately harming Black and Hispanic/Latino people. Although the "War on Drugs" continues to shape drug policy-at the disproportionate expense of Black and Hispanic/Latino people-states have taken some steps to reduce War on Drugs-related harms and adopt a public health-centered approach. However, the rhetoric regarding these changes has, in many cases, outstripped reality. Using overdose Good Samaritan Laws (GSLs) as a case study, we argue that public health-oriented policy changes made in some states are undercut by the broader enduring environment of a structurally racist drug criminalization agenda that continues to permeate and constrict most attempts at change. Drawing from our collective experiences in public health research and practice, we describe 3 key barriers to GSL effectiveness: the narrow parameters within which they apply, the fact that they are subject to police discretion, and the passage of competing laws that further criminalize people who use illicit drugs. All reveal a persisting climate of drug criminalization that may reduce policy effectiveness and explain why current reforms may be destined for failure and further disadvantage Black and Hispanic/Latino people who use drugs. (Am J Public Health. 2023;113(S1):S43-S48. https://doi.org/10.2105/AJPH.2022.307037).

Increased Attendance During Rapid Implementation of Telehealth for Substance Use Disorders During COVID-19 at the Largest Public Hospital System in the United States.

OBJECTIVE: The objective of this study is to examine differences between; telehealth and in-person visits during COVID-19 and in a pre-COVID-19 reference period; COVID-19 televisit completion for patients with varying engagement in treatment during the reference period. METHODS: Electronic medical record data were collected and analyzed with chi-squared or t-tests to compare patient demographics. Generalized estimating equations for estimating the odds of outcomes were used, controlling for demographics. RESULTS: Patients were 3.34 and 1.74 times more likely to complete a telehealth visit (n = 11,839) compared with an in-person visit during (n = 7,917) and prior (n = 15,497) to COVID-19. For patients on buprenorphine, patients with no prior in-person visits during the pre-televisit period were 2.26 more likely to complete televisits compared with patients with two or more prior in-person visits. For all patients, those with two or more prior in-person visits in the reference period were 1.27 times more likely to complete a televisit compared with a patient with no in-person visits during the pre-televisit period. There was no significant difference when comparing with patients who had only one prior in-person visit to those patients with no prior visits. CONCLUSIONS: In this study, outpatient substance use disorder (SUD) telehealth appointments were associated with higher odds of visit completion compared with in-person visits during and prior to COVID-19. Patients receiving buprenorphine, without prior in person visits, were more likely to attend if they did not have in-person visits prior to COVID-19. Regulators should consider permanently adopting telehealth flexibilities for SUD treatment once the federal emergency status has ended.

"When It's a Girl, They Have a Chance to Have Sex With Them. When It's a Boy They Have Been Known to Rape Them": Perceptions of United Nations Peacekeeper-Perpetrated Sexual Exploitation and Abuse Against Women/Girls Versus Men/Boys in Haiti.

Peacekeeping missions have been marred by reports of sexual exploitation and abuse (SEA) against local community members. However, there is limited research on how SEA against women/girls versus men/boys is perceived in peacekeeping host societies. In 2017 we collected micro-narratives in Haiti and then conducted a thematic analysis to understand how peacekeeper-perpetrated SEA was perceived by local community members comparing SEA against women/girls versus SEA against men/boys. Both male and female participants used language which suggested the normalization, in Haitian society, of both transactional sex with and rape of women/girls by UN personnel. In contrast, peacekeeper-perpetrated SEA against men/boys was viewed as unacceptable and was associated with homosexuality and related stigmatization. Overall, our results suggest that in Haiti, inequitable gender norms, the commodification of female sexuality, and homophobia result in SEA against males being recognized as a wrong that elicits outrage, while SEA against women/girls has been normalized. It is important to address the normalization of SEA against women/girls to prevent future violence and to recognize that SEA is also perpetrated against men/boys. Survivor-centered programs, sensitive to the needs of both male and female survivors, are required.

Rapid Telepsychiatry Implementation During COVID-19: Increased Attendance at the Largest Health System in the United States.

OBJECTIVE: This study aimed to examine differences in completion rates between telepsychiatry and in-person visits during the COVID-19 pandemic and a prior reference period. METHODS: The authors used electronic medical record data along with chi-squared or t tests to compare patients' demographic characteristics. Generalized estimating equations for estimating the odds of primary and secondary outcomes were used, controlling for demographic characteristics. RESULTS: During COVID-19, the odds of completing a telepsychiatry visit (N=26,715) were 6.68 times the odds of completing an in-person visit (N=11,094). The odds of completing a telepsychiatry visit during COVID-19 were 3.00 times the odds of completing an in-person visit during the pre-COVID-19 reference period (N=40,318). CONCLUSIONS: In this cross-sectional study, outpatient adult mental health clinic telepsychiatry appointments, largely by telephone, were strongly associated with a higher rate of visit completion compared with in-person visits during and prior to the COVID-19 pandemic. Regulators should consider permanently enabling reimbursement for telephone-only telepsychiatry visits.

Improving patient flow in acute psychiatric wards: enhanced bed management and trusted assessment.

AIMS AND METHOD: In three localities in a mental health trust in England, an enhanced bed management team was established to improve patient flow and reduce out-of-area placements. Trusted assessments were provided to support risk management and conflict resolution. Two measures of flow were compared before and after the team was established. RESULTS: The trusted assessment recommendation was for discharge in 70% of cases. The number of out-of-area placements was significantly reduced (P < 0.05), saving £616 876 over a 12-month period. Patient flow was significantly improved in one of the three localities as measured by patients/bed/6-month period (P < 0.05). In one of the other localities increased use of trusted assessment input and reduced numbers of patients being transferred in are recommended to improve flow. CLINICAL IMPLICATIONS: Mental health trusts should consider the establishment of an enhanced bed management team, including trusted assessment, as a safe and cost-effective approach to improving patient flow and reducing the need for out-of-area placement.

Functional and neuroanatomical effects of vaginal distention and pudendal nerve crush in the female rat.

PURPOSE: We tested the hypothesis that neuroanatomical degeneration near the external urethral sphincter (EUS) would parallel urinary dysfunction after vaginal distention or bilateral pudendal nerve crush in female rats. MATERIALS AND METHODS: A total of 28 female rats underwent bilateral pudendal nerve crush or vaginal distention, or were unoperated controls. Two days later a catheter was implanted into the bladder dome and 2 days after that (4 days after injury) urethral leak point pressure testing was performed with the rat under urethane anesthesia. The pudendal nerve and urethra were then dissected and prepared for light and electron microscopy. RESULTS: Leak point pressure was significantly decreased 4 days after pudendal nerve crush and vaginal distention (29.3 +/- 3.4 and 31.0 +/- 2.5 cm H(2)O, respectively) compared with controls (44.3 +/- 3.4 cm H(2)O). The percentage of nerve fascicles with degeneration near the EUS was significantly greater in the nerve crush (13.1% +/- 1.7%) and vaginal distention (7.2% +/- 2.2%) groups than in the control group (0% +/- 0%). There were fewer nerve fascicles near the EUS in the ventral half of the urethral cross section than in the dorsal half in all 3 groups and the percent of fascicles with degeneration was greater in the ventral half than in the dorsal half in the 2 injury groups. CONCLUSIONS: These results suggest that the pudendal nerve is particularly vulnerable to injury during vaginal distention in this animal model. The 2 injury models may be useful for investigating the pathophysiology of stress urinary incontinence.